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Table of Contents

Article

Invasive pneumococcal infection (i.e., bacteremia and
meningitis) and influenza are important causes of morbidity and
mortality among Medicare beneficiaries aged greater than or equal
to 65 years. In the United States, the estimated annual incidence
of pneumococcal bacteremia among persons aged greater than or equal
to 65 years is 50-83 cases per 100,000 persons (1), and such
infections are associated with a high case-fatality rate. Older
persons account for greater than 90% of influenza-related deaths
(2), and Medicare costs for influenza-related hospitalizations can
reach $1 billion each year (3). The Advisory Committee on
Immunization Practices (ACIP) recommends that persons aged greater
than or equal to 65 years receive at least one lifetime dose of
pneumococcal vaccine (1) and annual influenza vaccination (2) and
that hospitalization should be used as an opportunity to vaccinate.
This report describes an assessment of the vaccination coverage of
Medicare pneumonia patients who were admitted to hospitals in 12
western states * from October 1994 through September 1995 (fiscal
year 1995); the findings of this assessment indicate that the
opportunity to provide pneumococcal vaccine was missed for up to
80% of those hospitalized at any time during the year, and the
opportunity to provide influenza vaccine was missed for 65% of
those who were admitted during October-December 1994.

As part of an assessment of pneumonia treatment provided in
these states during fiscal year 1995, Medicare billing data
maintained by the Health Care Financing Administration (HCFA) were
used to identify pneumonia inpatients (i.e., those with an
admitting or principal diagnosis International Classification of
Diseases, Ninth Revision, Clinical Modification {ICD-9-CM}, code of
480.0-483.99 or 485-486.99 {pneumonia}, 487.0 {influenza with
pneumonia}, 510.0-510.9 {empyema}, 511.1 {pleurisy, bacterial}, or
513.0-513.09 {lung abscess}, or with an admitting or principal
diagnosis code of either 038.2 {septicemia, pneumococcal} or 038.41
{septicemia, Hemophilus influenzae} and a secondary diagnosis code
of 480.0-483.99, 485-486.99, or 487.0). A total of 87,230 such
hospitalizations were identified. This report includes data from
state-specific random samples totaling 5048 hospitalizations of
beneficiaries who were aged greater than or equal to 65 years, had
no inpatient care during the 14 days before admission, were not
admitted from another acute-care hospital, and were discharged
alive to other than an acute-care hospital. The state-distribution
of the 5048 hospitalizations was as follows: Alaska (4.1%), Arizona
(6.8%), California (five regional samples, 33.6%), Colorado (7.2%),
Hawaii (5.2%), Idaho (6.1%), Montana (5.9%), Nevada (6.3%), New
Mexico (6.6%), Oregon (6.9%), Utah (6.2%), and Wyoming (5.1%).
Inpatient data were abstracted by FMAS Corporation ** (Columbia,
Maryland) from hospital medical records and linked to Medicare
pneumococcal vaccine billing data for 1991 through 1995 and
influenza vaccine billing data for September-December 1994, the
periods for which data are available. Of the 5048 hospitalizations,
1312 occurred during October-December 1994, the primary influenza
vaccination season. The analysis for pneumococcal vaccine excluded
data for beneficiaries who were enrolled in a managed-care plan at
any time during 1991-1995 (n=500), and the influenza vaccine
analysis excluded data for beneficiaries who were enrolled at any
time during September-December 1994 (n=70) because plans do not
bill Medicare for vaccinations. State-weighted vaccine coverage
estimates and 95% confidence intervals (CIs) were calculated.

Of the 4548 patients who were included in the analysis and who
had been admitted during fiscal year 1995, 19.6% (95% CI=18.3%-20.9%)
had evidence of pneumococcal vaccination at some time during
1991-1995 (Table 1). This estimate included 12.3% (95% CI=11.2%-13.4%)
for whom a bill had been submitted for vaccination at any
time from 1991 to the date of admission, 6.9% (95% CI=6.1-7.7) for
vaccination from the date of discharge through 1995, and 0.4% (95%
CI=0.2%-0.6%) with vaccination during hospitalization. Estimated
vaccination coverage was similar in all age groups. Previous
pneumococcal vaccination was listed on 2.4% (95% CI=1.9%-2.8%) of
admission histories. Of the patients for whom there was no evidence
of pneumococcal vaccination at any time during 1991-1995, 66.6%
(95% CI=64.7%-68.4%) had at least one chronic condition (e.g.,
diabetes or chronic lung disease) associated with a possible
increased risk for serious pneumococcal infection, and 9.2% (95%
CI=8.1%-10.3%) had a condition (e.g., leukemia, lymphoma, or human
immunodeficiency virus infection) associated with substantially
reduced immunogenicity of the vaccine.

Of 1242 patients who were included in the analysis and who had
been admitted during October-December 1994, 35.4% (95% CI=32.3%-38.5%) had
evidence of influenza vaccination during September-December 1994
(Table 2). This estimate included 29.4% (95%
CI=26.5%-32.3%) for whom a bill had been submitted for vaccination
from September 1 to the date of admission, 5.3% (95% CI=3.9%-6.7%)
for vaccination from the date of discharge through December 31, and
0.7% (95% CI=0.2%-1.2%) with vaccination during hospitalization.
Estimated vaccination coverage was similar in all age groups.
Previous vaccination was listed on 4.7% (95% CI=3.4%-5.9%) of
admission histories.

Editorial Note

Editorial Note: ACIP recommends administration of pneumococcal and
influenza vaccines to inpatients as a strategy for increasing
vaccination coverage among adults (1,2). In addition, the American
Hospital Association Technical Panel on Infections within Hospitals
has encouraged hospitals to assist in vaccinating adults, suggested
that clinical staff obtain vaccination histories from all
inpatients, and suggested that recommendations for vaccinations
should be incorporated into discharge plans or implemented during
prolonged hospitalizations (4). However, the findings in this
report indicate that for elderly persons with pneumonia who were
hospitalized in states in the West, vaccination histories rarely
are included in the hospital medical record; in addition, indicated
vaccines consistently are not provided to inpatients and are
provided infrequently following discharge. Specifically, the
opportunities to provide pneumococcal and influenza vaccines were
missed for up to 80% and 65%, respectively, of eligible persons.

An important feature of hospital-based vaccination programs is
that they permit the targeting of vaccines to persons within the
health-care system who may be at increased risk for subsequent
serious pneumococcal disease and influenza. Previous
hospitalization has been a risk factor for subsequent serious
pneumococcal infection, and modest levels of inpatient vaccination
could substantially reduce admissions (5). High coverage levels can
be attained in hospital-based influenza vaccination programs,
although such programs must be well organized (6); optimal coverage
may be attained when standing orders are written to allow nursing
staff to offer and administer vaccine to patients who do not have
contraindications.

Low coverage levels, regardless of patient setting, may
reflect physician and patient beliefs that these vaccines are not
effective, fears about adverse reactions, and concerns about
reimbursement. However, influenza vaccine is both clinically
effective and highly cost-effective (7); and pneumococcal vaccine
is approximately 75% effective in preventing invasive pneumococcal
disease in persons aged greater than or equal to 65 years,
including those with chronic diseases (8). Medicare has paid for
pneumococcal vaccination since 1981 and for influenza vaccination
since 1993.

One important limitation of the analysis described in this
report is the potential underestimation of outpatient vaccine
administration. Bills submitted before 1991 for pneumococcal
vaccine would have been missed, and Medicare billing data miss
approximately 20% of influenza vaccinations in the fee-for-service
population. In addition, vaccine may have been withheld for
legitimate reasons not apparent from the medical record. However,
inpatient vaccination data presented in this report are highly
reliable because the actual medical records were examined.

Based on Behavioral Risk Factor Surveillance System (BRFSS)
estimates for each state in 1995, among persons aged greater than
or equal to 65 years the median pneumococcal vaccine coverage was
only 37%, and only 59% had received influenza vaccine during the
previous year (9). The BRFSS estimates in 1995 and the findings in
this report underscore that hospitalization represents an
opportunity to vaccinate Medicare beneficiaries who may be at high
risk for subsequent severe pneumococcal and influenza infections.
The results of this assessment are being used by HCFA Quality
Improvement Organizations (formerly Peer Review Organizations) to
encourage physicians and other providers to administer needed
vaccines during or immediately following hospitalization.

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